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Menopause Matters

Counseling for Continuance

Improving Use of ERT/HRT

Marilyn Rothert, PhD, RN

Despite the benefits of estrogen replacement therapy (ERT) and hormone replacement therapy (HRT; estrogen plus progestogen), many women who initiate therapy discontinue it shortly thereafter. In fact, up to 50% of new ERT/HRT users stop therapy within 1 year.¹ A review of Kaiser Health Plan records showed that the 3-year continuance rate for ERT/HRT was less than 20%.²

Discontinuance is ascribed to several different causes. These include side effects (eg, heavy/unscheduled uterine bleeding, mood changes, breast tenderness, bloating, water retention), lack of knowledge about the risks and benefits of ERT/HRT, anxiety about unnecessary treatment, and failure of the treatment to meet expectations (eg, immediate control of hot flashes).

Improving Continuance
Continuance is defined as using a medication over a period of time and at a dosage needed to achieve the desired effect. Adherence is a neutral word that can be substituted for continuance. Compliance, a term widely used to describe use of a medication as instructed, connotes yielding or obeying rather than following a mutually agreed-upon course. Thus, this term should be avoided.

In a 1998 consensus opinion, The North American Menopause Society identified several strategies that clinicians can implement to improve continuance of ERT/HRT.³

Involve women in the decision-making process. Mutual decision-making can greatly increase the likelihood of adherence to the negotiated plan.⁴ Information should be tailored to be relevant to each woman's background. Open communication and respect for the woman's opinions are needed to enhance the partnership relationship and to promote trust. If a woman chooses not to take ERT/HRT, clinicians should respect her decision and explore other strategies to meet the clinical goal.

Clearly explain the benefits and risks of ERT/HRT, personalizing them if possible. Information should be provided about the roles of exogenous estrogen and progestogen, their side-effect profiles, and their potential long-term effects on the risks of heart disease, osteoporosis, and breast cancer. Clinicians should try to answer women's questions, but they should acknowledge the conflicting data in the literature. Written information and Web site addresses for reliable sources (eg, The North American Menopause Society; see Box) should be provided. The goal is to help each woman make the best choice for her and, if she chooses ERT/HRT, to identify the regimen and route of administration that best suit her needs.

Determine women's preferences for ERT/HRT early in the decision-making process. Clinicians should ascertain women's desired outcomes and their greatest concerns. These preferences should be used to modify the regimen to enhance the likelihood of continuance.

Provide educational information that women can understand. Continuance rates are higher among women who are knowledgeable about menopause, who participate in decision-making, and who understand what they are taking and why, as well as what to expect. Suggestions for improving communication include the following:

• Give the most important information first.
• Emphasize essential instructions by repeating them.
• Ask women to repeat essential elements of the message, especially specific actions required.
• Provide instructions orally and in writing. o -Listen to their concerns and questions; provide adequate time to address them.
• Encourage women to bring someone with them to hear the instructions.

Help women to systematize medication-taking. Clinicians should work with women to find a regimen that is not only safe and effective but that also suits their lifestyle. Regimens that are simple, convenient, and inexpensive have the highest continuance rates. Women should be encouraged to use intervention cues-such as clock times, meal times, and daily ritual times-to remind them to take their medication.

Follow up frequently. Clinicians should schedule regular contact (every 3-4 mo), through visits or telephone calls, especially early in the course of therapy. They should monitor progress and remind women to call with concerns. Women should be informed that it might take a few months of altering doses, drugs, and timing to find the best individualized regimen for them.

Recommendations
One threat to ERT/HRT continuance is an experience that does not meet expectations (eg, perceived lack of efficacy, unanticipated side effects). Above all, clinicians should be honest about data available and about any gaps that exist. They can also help women to develop specific, realistic goals. As women's health beliefs, needs, and preferences may evolve over time, clinicians should modify their ERT/HRT regimens to reflect those changes.

The type of regimen is important. Continuance appears to be greater with oral ERT than with oral HRT, and with cyclic HRT than with continuous HRT.² Transdermal ERT has been associated with a lower rate of continuance than oral ERT.⁵ The overall evidence, however, is inconclusive. Clinicians should discuss the tradeoffs and expectations for each treatment option, including the likelihood of experiencing uterine bleeding and other side effects.

Conclusion
Primary factors influencing ERT/ HRT continuance are those related to the woman herself (eg, her environment, her expectations) and the regimen itself (eg, transdermal vs oral, cyclic vs continuous). The most successful regimens are those that are simple, do not interfere with a woman's lifestyle, and are inexpensive. Continuance rates are greater when women have participated in decision-making, when they feel that their expectations have been met, when their clinicians have listened to and respected their concerns, and when they have received adequate information regarding their therapeutic progress.

References

1. Faulkner DL, Young C, Hutchins D, McCollam JS. Patient noncompliance with hormone replacement therapy: a nationwide estimate using a large prescription claims database. Menopause. 1998;5:226-229.
   
2. Ettinger B, Li D-K, Klein R. Continuation of postmenopausal hormone replacement therapy: comparison of cyclic versus continuous combined schedules. Menopause. 1996;3:185-189.
   
3. Achieving long-term continuance of menopausal ERT/HRT: Consensus Opinion of The North American Menopause Society. Menopause. 1998; 5:69-76.
   
4. Rothert ML, Holmes-Rovner M, Rovner D, et al. An educational intervention as decision support for menopausal women. Res Nurs Health. 1997; 20:377-387.
   
5. Ettinger B, Pressman A, Bradley C. Comparison of continuation of postmenopausal hormone replacement therapy: transdermal versus oral estrogen. Menopause. 1998;5:152-156

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